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This comprehensive program review highlights the achievements, challenges, and areas for improvement in Hampshire House’s program. Topics include staff retention, training hours, utilization rates, program completions, client-related data, medication incidents, satisfaction surveys, and action plans.
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HAMPSHIRE HOUSE Comprehensive Program Review May 30, 2014
PROGRAM HIGHLIGHTS Highlights: • Program renovations were completed – expanded bed space to 45 • Achieved ACA Re-Accreditation: 99.4% • FBOP Monitoring Results Best Practice/Promising Practice: • Staff Retention – keep staff engaged, valued, staff is invested in program • Utilization of SecurManage • Relationship with NH-USPO
CHALLENGES Challenges • Transition Process for new SOW • Developing PREA procedures • Developing ongoing Accreditation record keeping process
STAFFING Staff Turnover Rates Staff Retention Rates Overdue Performance Evaluations Staff Training Hours
STAFF TURNOVER RATE (4/1/13 - 3/1/14) • Last CPR (December 2012 – May 2013), the turnover rate was 24.1% compared to 31.3% for SJS Data obtained from HR Retention & Turnover Report
STAFF RETENTION RATE • The 6/2013 Retention Rate Data for SJS and CRJ Overall = Not Available (N/A) Data obtained from HR Retention & Turnover Report
OVERDUE PERFORMANCE EVALUATIONS (October 2013 – March 2014) • As of March 30, 2014, there were 2 FTE performance evaluations that were late. • The 2 evaluations in question were due at the end of March. They were submitted to HR within the first week of April. • Last CPR: • At the end of May, 2013; there were 2 FTE performance evaluations overdue. Data obtained from HR Personnel Summary
Staff Training Hours • Current CPR: (October 2013 – March 2014) • Total of 391 training hours • Average of 65 training hours per month • Average of 3.6 hours per staff member per month or 21.48 over six months; 54% decrease from last CPR • ACA occurred in Dec 2013; major thrust of training completed prior to accreditation • Last CPR: (December 2012 – May 2013) • Total of 807 training hours • Average of 134.5 training hours per month • Average of 7.91 hours per staff member per month or 47.4 hours over six months Data obtained from MMRs and HR Training Reports
PROGRAMMING • Utilization • Program Completions with: • Employment • Permanent Housing
Utilization (October 2013 – March 2014) • The current utilization rate is 95.1% (this is a 2.6% increase); Hampshire House had an average of 30.4 clients. • Last CPR: Utilization rate was 92.7%; an average of 29.6 clients Data obtained from MMRs & Utilization Report
Program Completion • Average of 75% of clients successfully completed the program. Last CPR: 76.7% • Average 53.6% of clients completed with employment. Last CPR: 61% • Average of 100% of clients completed with housing. Last CPR: 97.6% • Average of 25% of clients were terminated before completing the program. Last CPR: 23% Data obtained from MMRs Data obtained from MMRs
CLIENT RELATED • Clinical Hours • Walk-Aways • Medication
Clinical Hours • Total Hours = 1,644: Last CPR = 1,793 • (This is a 8% decrease) • Total Life Skills Hours= 289.5: Last CPR = 172 • Total Cognitive-Behavioral Hours: 1354.5: • Last CPR = 1,621 • Average Total Hours per client/month: 8.5: • Last CPR =9.3 • Average Life Skills Hours per client/month: 1.5: • Last CPR = 0.9 hours. • Average Cognitive-Behavioral Hours per • client/month: 7: Last CPR = 8.4 hours. Data obtained from MMRs
Walk-Aways(October 2013 – March 2014) • Last CPR (December 2012 – May 2013), 0 walk-aways Data obtained from MMRs
MEDICATION INCIDENTS & OCCURRENCES(October 2013 – March 2014) • Total of 0 medication incidents and occurrences (200% Decrease) • Last CPR (December 2012 – May 2013), 2 medication incidents Data obtained from MMRs
Quality Assurance Key MMR Results Satisfaction Surveys
KEY MMR RESULTS (October 2013 – March 2014) • 100% of clients successfully completing the program were reunited with their family • 100% of clients successfully completing the program had permanent housing; last CPR = 97.6% • 100% of clients successfully completed the program with a full discharge plan • 100% of discharge plans developed with family involvement • Average of 97.9% negative drug tests; last CPR = 99.61% • Zero written deficiencies from outside funders
CPR ACTION PLAN • Library – make sure that Paul Swindlehurst receives a copy of all the donors • Discuss Transitional Housing at Think Tank meeting – what is the feasibility of utilizing the apartment building’ next to Hampshire House as a possible transitional housing program; • Revisit the existing SJS Client Satisfaction Survey • Ensuring that a minimum of 60% of clients take the survey (August CPR – only 33% had responded) • (March 2014 survey = 21/32 or 66% responded) Keep an Eye On: • Wellness - Hampshire currently working with HCH on diabetes and smoking cessation classes for clients • Need to improve tracking of wellness trainings • Renovations/Expansion of Hampshire House • Impact on programming – yes or no? • Utilization – concern about keeping HH full after expansion is completed